P - 48351Building BUILDING Permit No.: � I� �
Inspections RESIDENTIAL APPLICATION Re�eivea By:
763-s�2-3604 CITY OF FRIDLEY �a�� vate xec'd� ' j�'
763-502-4977 FAX EFFECTIVE 1-1-2012
DATE % � Z�" YOUR E-MAIL ADDRESS /li �,Si�J E!� '� M S� - C. � Nl
SITE ADDRESS �a��� / C�C6/L�I �R , F/=-� p �t �
THIS APPLICAN'T IS: ❑ OWNER �ONTRACTOR
PROPERTY OWNER/ NA�:_ �J��y �j���S
TENANT ADDRESS: �� /f,ged�' CITY STATE ZIP
PHONE:—rP % 7— � 3 �� — �� �'Y
CONTRACTOR NAME: S'�.•1E-/J�-/(!t('—T'
SUBMIT A COPY OF
YOUR STATE LICENSE STATE LICENSE # ,� �i �p� %% % LEAD CERT NUMBER EXP:
AND CERTIFICATE OF ADDRESS: _�/�� HI� �Y D� CITY F�i t7 I.£- �/ STATF{y �ZIP�?'Z
INSURANCE PHONE Z� �%7 � Io FAX �'�
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE ❑ ADDITION ❑ GARAGE/SHED DOWS
❑ BASEMENT FRVISH ❑ ROOF O DRAIN TILE
❑ DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION 0 ADDTITON
❑ MAINTENANCE/REPAIR MODELING
DESCRIBE WORK BEING DONE: ��P llrG fi �7�'M I�N� (•J II�DC� I,J 1TN S�f'M �. i/ 2{� "� 6�i �✓£.C.4 Y ST�'1C-
SIZE OF IMPROVEMENT LENGTH WIDTH HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE 1. Existing Floor Plan ,
GARAGES ❑ ATTACHED GARAGE 2. Proposed floor plan
PROPOSED SIZE: O DETACHED GARAGE 3. List of structural members to be uted
PROPOSED HEIGHT:
SIDING FOR NEW CONSTRUCTION INCLUDING DECKS,
O Vinyl ❑Soffit SIDING/SOFFIT/FASCIA �DITIONS_ & PORCHES SUBMTI:
O Aluminum ❑ Trim REMOVED? O YES ❑ NO 1. Site Plan/Survey showing the exisring structures
and proposed project.
O Other ❑ Fascia 2. Two sets of construction plaz�s
WINDOWS l2�'�"�4'�� 3. EnergyCalculations
IN EXISTING OPENINGS �Yes ONo LOCATION OF WINDOWS '— urr�I"� FOR WINDOWS — PROVIDE U-VALUE AND
OR FOR NEW OPENINGS-DESCRIBE SIZE OF � A-1L v � n( — �.1�T7�Far MANUFACNRE STICKER ON WINDOW.
OPENING CAANGES &
TYPE OF WINDOW TO BE INSTALLED D�u � N`` � G NUMBER OF WINDOWS
ALL NL;L;a AKI; BA51;D V1V VALUA"1'LUN,INCLUDING THE COS"I' OF LABOR AND MATERIALS:
_ (USING THF,,,1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION � Z���'� ��� nrrrTV s nrrv •rvn�
Permit Fee
Plan Review
Fire Surchazge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Control
Pazk Fee
Sewer Main Charge
Total Due
$ y3, Si� See Back Page for Fee Schedule
$ 65% of Building Permit Fee
$ � 5 O .001 times the total job valuation
$ d :0005 x Permit Valuation Minimum or .50
$ $5.00 (State Licensed Residential Contractors)
$ $2365 per SAC Unit (Plans to MWCC for determination)
$ ft+6ft= ftx$25=$
$ $450 Conservation Plan Review
$ Fee Determined by Engineering
$ Agreement necessary ( ) Non Necessary ( )
$ Make checks pavable to: Citv of Fridlev Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley d with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to wrth a permit on site; that the work wili be in accordance with the
approved plan in the case of a1 rjcv� �c�� i vie�i an pprova f plans. -,�
SIGNANRE OF APPLICANT � `i��t5� // PRINT � Sacc, ScJ�I D.S/t,�_n na� L/.I //�
Fairss rt�prqvu*d t?Rt8 RSJ. 2070-0155 E�^rire� •CT3'ad11
�
��� !4#'PLl�ATIQN �C?R �lRi�S
U.�. Er�vr�o�n��rv�R� �€�r�����r� A���c�r Ts� Co�r��c�r L�,a-Sas�o P��rr Ac�v��r� �n��tor� R�ov�►rrno�s
tmpor#ant: T'[�►is app€icatdara is t�:quired by 4i3 ���i §745.89�a} fc�r re�novatiar�s and is � substitufe for the feYCer requir�f �y
�745_226 f�(2� f�r ahaterrtent. �nsuit tt�e xnstrr�sr�ir�ns for �i�nrts a��aty�r�g f� ��tific�tir�n to canduct Ie�d-based �i#aes ar renovatians.
�or abatement activ€ti�s, persona se€�tcing 6ntiiaiduat �ea#if�cat�n �laaut€f use the A��Iicatian iQr' dntis�d€r�als ir�steac� aa€ th�s fc�tm. Ptease
fil[ t�ut �II seciir�ns. �`y�e �r prin# respan�es in bla�k or biue ink onty,
A, Applicatacen Type (select +vnly ane b�� fram Qption 9, 2, 3 or 4 0� �estiv� Aj
1. � Qption 1: R�r�ovation RenRair and Pain�rua (RRP a�d Qust Samplina T+echnic�an} Frm Cer�ficai%trr�
�
�
I�dial
(� or
Rer�ov�tion, Repair a�c! Paintirrg Fs� Certification
Ret�fifi�on
� Aha#ement Firm CertRfcafion ($�D far #irst ]urisdiction and
$35 fcu eacir �ddi6onal jurisdictFan — tist jce�dict�on(s) be[ow}
lnittial Recesii�icats�
V �� �
L.ist abatetnent jutisd�tian(5):
Combinatiara Ab�teei�ntiRRP Fims Cer't�fication �550
fvr RRP and a�re abatement junsdi�n. �5 for ea�h
acldi�iatai abatertte�rt ju�dic�on -- list abatemet�t jcu�is+di�tla�{s} E�etovv}
�) tS�►i 2} t:65�} 3) t5�2o1
{PEease rwte, if app�ting fqr mc��e th� thr�e jwis��lia�c�s atki an at#cii#�onal $35 iar sach jurisdidion ar�d �sf them nn a
separa�e sheet of psper}
3. �t7ption 3: Amend �xis�►g,Ce�tt
�} Update firm irtformatia� (na fe� re.�uiret[}
� Add af�afemer►t �r�sdidian {�S p�emr aba#�n�t jurisd➢c�tiarn)
List ab�emerrt jcttisst#dian{s} being adder� to ycwr eycisting cer#ifica6on:
1j ($35� 2} ($70) 3} ($1�
4_ Option 4: Rgrr�aace Certifi�ate
� Replace C�ttificate ($95j
s. Enter tota! app�ication fee � 30t�
Note 1: See insfnu�iarts �r addition�l %e �fcxrna� artc! e�mpies af r�qr�+e�i fees.
Rlote Z: ff yau ane a federaEly rscognizerJ lnd�aa Tribe sc�king c�efif�ca6on as a firm chedc yes in the ques�c�r► belaw and see Fees
Sc�edute in th�e irrstn�ts`octs fo deierrnine fiee �equired.
Yes � No Q lcxiicate wheth�t yoa �re a federatly-recogrdzz$d lndia� tribe seelcing c�rt�f�cation a& a i'um.
C. Appticant Irtftumativn
Mame of Firm: '�a' W�1"1C13ft
susiness �aress: 8917 H�dcoryr Cir., Fridiey, MIV 55432
Straetl�tior�ess, Su�+e Nurnber (PFeaSe n� P.U. �cj C�y sta� �ip Cade
Mailing Add�ss:
('rf di}F�r+er�t rra�m at�ove) street add�s, su� Num�r �y �ate 2u► Code
Name of Aitesting lndivi�ual: �W@I1(�StUd Et'IC �
last First I�Aldd�e
F�,'S Phone#�: 51�-2ss-�7os �,��. ,�,,,,�,�,�� r�,�„��: s��-�-77as e,�.
Attesting lndividu�i's E-rnait A�idress: iT't@SW6C1�1'i1Sl1.001'Yl
F�stt? �d CN� No 2£s'+�-t}��v E�ees t0i',1E1 i
D. WetiSrt+� Lfs�irig '
Ctnce c�r�ifi�ci yaur €rrrr� v�ril� �ae tisi�d on EPA's web �ased s�r� toEo#. Pi��se �E�ct �he �pe ofi service{s� yt��r �rm �li '
prc�vide: �
� Renovation � Evaiu�tic�r� [� f,.ead Abaiement �
�. L�ad=B�ased Pairr� A�tivity c�r E�novatioa� Vic�iat�c�n[s� , {
;
C3c�e.s the firm have any past. Fresent, or �teerxding leaci-based paa�t �rioEatiQns af EPA, "Y�s � No �
S`tate, U.S. #err�ory, tar 1�►ctiarr trit�at #and�s) r�aiions� [f y�s, p�ase a#tach � v�citten �anatic�n.
FE ��tti�cat�c�� �tat�rne3tt
1 hetetsy att�si anc! affir►r� i� to��swing:
• The irsforrnation irucc:#uuded on this �pl�a�, iriduc�g any �tfiacfi�r�enis. i� #n�e �d accu�#e to � E�t c�f �► bei� and
kns�rv[�ige.
• This iam sha� �ly �npb�r appropriatefY qua�€ �s�ielats 10 �rtdenct pair� at�iv�ies �nd renov�.
� This �+rm 8t�d 'tts ett�Oye�s stta� fd#ioyv fhe u�ork pt2tc#xx: StandBtds se� fc�tth p� 40 ��R § 745.22? for Gc�tzit�ting lead-bas�ed
�in# activities or � GER § 745.85 for conduc�ing rereavations �t aN times,
• 1�cknawt�;�ge thst a�y� certiftt�iion i5suec3 ��tart# tu tt�is app�icatiai. inc�dittg �u�y attac:t��nts, vv�► be su�bjecx tv re�oca�n
if issua� wss 3�a�ed am inc�r� o� i�uate i�tforrn�f�n i�at matec+aiy a�c€ed � ds�c�r► ta iss�e tiva
�' 'r—�
�'t@i F8�3. f '� ��'i 2
l�tte�#ing Inda�ric�i's Si�gnatur+a `t'ifia Dat� Signed
(Pie:r� s�}n �egibt�r wwth�rt the boundar� o# � b�c above.)
Pr;�ac� �t saare�e�+c -rn�s sta��m;s Fe�wwea r�►�� �+ �te �++�r Aa or � �vo, s �,s.c_ §�5za. �sne a� ser �o � �maam �s ao
C.F_Fi. P�61. 745. aaxS 75 t1.S.G. §�28$2 Artd 2�4. 'ilx: ii7fOm�8Gf�1 flit �vs 413ff7F Yvr� I!@ tesecl tD �1f � `S e�y fui �s
co�6uct te�#•b�sed t�t activ)fies and frt tar�et ��d . . c�f tius' '��c�cy: haa�+rer. tlse
iau�e !a pt�vide tri�s �eiomEa�uxt +rr�Y deFay or pte�ent an �pp�nt's . This ` ' may tae d� u� asui �i�ed �
tfl: El�A ertq�oye�s, Ear+f�rs. �es cu aihers wf+en �g cl�s �at are ra�Rr the pu�pcs� �v�R�ictt ��S ss � snd
when if� i�r#cxmatkm � r�ecessat� tu �mple#e U�e #ask: a a�ember of C�ess in se�e �s a requast made'+�Eh Y�[u �nt a»d at Ywsr 6Bl�8if; io
appt�pria� �ar elafoccertreaf age+=t�+� ftx '�J. �9< � tx �niin9 s�eC�`�c �8#�es. Cudes or te�(ai�ns and tlris
i�r�atirui is teter�! � tt�t ` an " ' body wtcsn suett �'e is w�at�De wsHr � PutPos� forwf�iCh ltws int�u[nati�
is �ed artd � EPA �#� tlni6ed Sfa�es #sa� am i�test ��te p : ar�c! t�e a# t� ira�aszuy, the Genetsl Serv�s Admitvsirafi�, fhe
C'aea�seal kcx:ounting t3tf�e 8nd oltter Faderal, 8fabs. an�S Locat A�es ka� attthotized 2a�ii� [#3teC Us th�. �omtaiKxr�
Be�eue you maN y� at�li�on a�wd cert�icatian fee, m�tc$ sure thai you i�av�.
• F�d +aa�t aN app�cabte seaior�s of th� ep�n
• S4gnecl and +d�ted the applic�tion
o Made a oopy af yauz' appiic�ti+�n f�t your �es
• ErtcbsE�d �e app�Ci�e certi�tion fees {c.�e�dt tx' rr�y t�'cierj
• Matc� d�edc paYabE�
• Printed "tead Proq!ra
o �17f iT40[E q'1fOttT��OLl,
a�r ari�ar ��
U.S. EPA
�.ead User Fees
R.O. Box 979ti72
St. Lottrs. �Ci fi31 �7-900Q
SWENCRAFt G31►IiPEN�'RY, �:1C °
b'9'iT NlCKi)FtYDR NE ' . ' S{��: :.
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